Kyphosis and Scoliosis

What is it?

The spine normally has a straight alignment when viewed from behind and three curves when viewed from the side. The neck (cervical) is lordotic, or curved with the concavity at the back, the chest area (thoracic) is curved in a forward direction, and the lower back (lumbar) is curved once again towards the back.
 
Scoliosis is a three-dimensional deformity where the spine has an abnormal curvature when viewed from behind. This sideways curving and twisting (rotation) of the spine can result in chest and waist deformity, and the alignment of the shoulder and waist is often altered.

Kyphosis is purely an excessive forward bending of the spine when viewed from the side. There is no associated twist or sideways deformity. Kyphoscoliosis is a condition that comprises both kyphosis and scoliosis.

What causes it?

There are many causes that can lead to these spinal deformities.

They may be due to a birth defect (congenital) where one or more vertebrae fail to develop normally, resulting in asymmetrical growth.

 

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          Image used with permission from Dr RN Dunn

This reconstructed CT scan demonstrates kyphosis (forward bend) and scoliosis (sideways bend). The malalignment causes spinal instability and can cause nerve root compression.

 

Kyphosis is frequently seen in infective conditions of the spine such as tuberculosis where the front part of the spine (vertebral body) is destroyed and collapses, resulting in the forward curved position.

Many neuromuscular conditions, such as cerebral palsy, spina bifida and muscular dystrophies, cause muscle weakness and long abnormal curves (scoliosis). This can be troublesome in the patient’s everyday usage of a wheelchair.

Inadequately treated fractures from trauma may result in both kyphosis and scoliosis.

Common causes include the group described as “idiopathic” (where the cause is unknown). This is a well-recognised group of young, tall, slim girls developing scoliosis during their teenage years as they go through their growth spurt. 

In later life, asymmetrical discs and facet joint (the joints between the vertebrae) degeneration may cause segmental instability and degenerative (wear and tear) scoliosis.

What are the symptoms?

Symptoms vary based on the cause. Congenital (inborn) deformities may be incidentally picked up on a chest X-ray done for other reasons, as these children often have other associated problems with their kidneys and hearts. 

The idiopathic group is often noticed at around 10-12 years of age when a posterior thoracic (torso) prominence is noted or hip or shoulder asymmetry.  It is usually not painful. There may be breast asymmetry which concerns the young teenage girl.

The degenerative group usually presents with both back and leg pain due to narrowing of the spinal canal and nerve root foramina, which causes compression of the lumbar nerve roots. These patients may also complain of progressive loss of height and increasingly prominent hip bones.

How is it diagnosed?

Once the deformity is noticed by the patient, the treating specialist will ascertain the history to define the cause. A clinical examination will include the forward bend test which exaggerates the chest wall prominence around the shoulder blades.

The diagnosis is confirmed on a full-length X-ray taken both from behind and the side while standing. Further views in flexed or extended positions may be needed to determine the flexibility of the curve. MRI and CT scans may assist in determining the underlying cause.

How is it treated?

Any dangerous underlying factors need to be excluded. If the deformity is mild, the patient may be carefully monitored and if no progression occurs, left untreated. If progression is expected based on the patient's age, curve size and type, intervention is required.

Bracing is an option, but with poor compliance it is not always successful. Patients find it hard to wear the brace for the required 20 hours per day. Surgery is the mainstay of management of the larger, progressive curve; it is dealt with in a later chapter.

Does this treatment have any complications?

All surgery involves risk. The general risk of infection is present and relatively low at around 0.8%.  It is lower with the anterior approaches. There is a risk of non-union, or failure of the bone to fuse. Should this occur, the instrumentation will fatigue and break at around 12-18 months post-operatively with pain and a loss of correction.

The risk most feared is neurological injury (paralysis). Although this risk is ever present, it is rare, with a chance of 1:300 of any neurological event from some numbness to total paraplegia (unable to move or feel legs). This can occur from the corrective process and increased strain on the spinal cord or from reduced blood supply to the cord. 

To reduce this risk, some specialists use spinal cord electrical monitoring during the procedure, although this is not fail-safe and has its own technical challenges. Should there be a problem in the immediate post-operative phase, urgent instrumentation removal may be required. Speak to your specialist about a more comprehensive list of possible complications (see the section Your Back Operation).

What are the long-term expectations?

This depends on the type and underlying cause. Severe scoliosis, greater than 70 degrees, poses a risk to lung function, and greater than 100 degrees increases the risk of mortality. Smaller curves remain a cosmetic and psychological issue, but not a medical threat.

Curves less than 40-60 degrees in the younger age group usually will not progress after maturity and do not have an adverse effect on enjoyment of life. Curves greater then 60 degrees will progress and surgery should be considered.

The degenerative type tends to progress and increasingly causes nerve root pain.

 

 
About my-spine.com

This website is a patient resource compiled from information from leading spinal surgeons practicing in South Africa and complements the My Spine – Lumbar and My Spine – Cervical information booklets that you can obtain directly from your spinal specialist. You will find information about spinal conditions and treatment on this website.

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